MDs, DCs, NDs and LAcs: Who is a Physician?

A doctor level, non-MD academic friend from a conventional medical school who has expertise in complementary and alternative medicine inadvertently stepped into a militarized zone the other day. On a conference call with a multidisciplinary group of practitioners, he wished to make a distinction. He first offered a generalization about the roles of “chiropractors, naturopaths and acupuncturists.” Then he distinguished these from what he called “physicians.”

All of us knew that this studied academic was referring to licensed medical doctors, a.k.a. the kings (and queens) of the hill in U.S. medicine. At the same time, many of us were acutely aware by his comment that, while common and even professional usage of the term “physician” may connote MDs, legal realities are shifting. In fact, trends suggest that one endpoint of the movement toward integrative medicine is that “physician” will increasingly umbrella a rainbow of disciplines.

US Department of Labor bestows “physician” on DCs and NDs

The subject is front-and-center recently for a couple of reasons. First, the United States Department of Labor recently published O Net Online which replaces the Department’s Dictionary of Occupational Titles. (1) The language under the section 29.1011 titled “Chiropractors” notes that sample titles of these practitioners include “Chiropractic Physician” and “Physician.” (2)

Profession #29-1199.04 is listed as “Naturopathic Physicians.” Among job titles for this profession are “Naturopathic Physician,” and “Physician.” (3) The American Association of Naturopathic Physicians (AANP) boasted of its success in working with the Department of Labor to create this positioning in an October 14, 2009 note to its members. (4)

In Florida, the LAcs are APs – “Acupuncture Physicians”

A search for “Acupuncturists” on O Net Online finds a page which states merely that research is underway and that they haven’t established anything definitive yet. An honest accounting of use nationally will find that in the state of Florida, licensed acupuncturists have gained authority from the legislature (if not through accredited, doctoral-level educational means – more on this below) to legally work under the professional title “Acupuncture Physician” (as in Jenny Smith, AP). The Florida State Oriental Medicine Association actively promotes and defends the use. (5)

In short, depending on what state you are in, or what federal document you may be reading, or into whose office a patient is walking, the term “physician” term may be referring to not just MDs but also to NDs, DCs and even LAcs, I mean APs.

Some trends toward expanded use of “physician”

The use of the term "physician" by these so-called CAM professionals is trending upward. Naturopathic physicians have been claiming the title since a new generation began re-shaping the field starting in the mid-1970s. They’ve gone back into most of the handful of states where NDs were still licensed and since replaced “drugless healer” acts with modern practice acts in which physician is part of the title and at least some prescription drug rights, typically, in the scope. (The O net Online notes that naturopathic physicians “may also use prescription or legend drugs.”) Hawaii was the profession’s most recent update, in 2009. In the profession’s slow expansion to new states – now at 15 – the right to use the physician title is across the board except California where the California Medical Association exacted a concession that these affiliates of the AANP could only call themselves “doctors.”

Success in claiming the physician title, linked to privilege, status and particularly third party payment - some insurers will only cover certain services if provided by a “physician” – figured heavily in an October 2, 2009 mailing to members from the American Chiropractic Association (ACA). The ACA credited its hard work for insuring that the title stayed in the language defining the Federal Employee Benefit Plan. Blue Cross Blue Shield, which manages the plan, attempted to demote chiropractors to a status as “other health care providers.” (6)

While the chiropractic field is fiercely divided over its naming, with many adamantly opposing the use of the term “chiropractic medicine” (preferring “chiropractic”), resistance can diminish if more income opportunity is associated with a more medical positioning. A federal lobbyist for the field recently shared his view that opposition is waning as physician status is increasingly a component of the chiropractic medical profession’s Congressional agenda.

“Certified advanced practice chiropractic physicians” in New Mexico and an “entry-level doctorate” for AOM

A place the chiropractors are watching is the state of New Mexico which drew a good deal of attention at the ACA’s fall 2009 national conference. Chiropractors in New Mexico passed legislation this year that establishes the category of “certified advanced practice chiropractic physician.” This category, distinguished from chiropractor and requiring additional education and certification, is defined as having “prescriptive authority for therapeutic and diagnostic purposes as authorized by statute and stated by the board .” (7) The ACA has named a task force to look into this development.

For licensed acupuncturists, over the last decade roughly a half-dozen schools have begun offering small, accredited, clinically-focused Doctor of Acupuncture and Oriental Medicine programs which allow graduates to use D.A.O.M. after their names and “Doctor” in their title. But the big push will be around the profession’s movement toward an “entry level doctorate” from the current Master’s level of basic education. In the spring of 2008, the Council of Colleges of Acupuncture and Oriental Medicine endorsed this direction. The physician question will certainly follow – and may yet pop-up in anomalous, legislated re-definitions such as created the Acupuncture Physician category in Florida.

The AMA’s push-back in its Scope of Practice Partnership campaign

These changes have not gone un-noticed by the American Medical Association. In 2006, the organization formed its Scope of Practice Partnership to battle against scope expansions into its turf from a huge array of fields, including nurses, optometrists and psychologists, as well as licensed DCs, MDs and LAcs. A recent analysis of state legislative issues the AMA was watching in 2009 found that 24 of 154 related to these 3 fields. Often the AMA interest was in opposing the licensing of “naturopathic physicians” and a cluster of others were against expanded prescriptive authority for NDs and DCs. (8)

The AMA’s view is supported by the 2008-2009 version of occupational titles published by United States Department of Labor. The stern clarity of the language is hardly aligned with actual use in the various States that make up these United States: “There are two types of physicians: M.D.—Doctor of Medicine—and D.O.—Doctor of Osteopathic Medicine.” (9) This faulty language must be reassuring to the leaders of the AMA’s Scope of Practice Partnership campaign – positively a pacifying thumb-sucker of a throw-back to some remembered good old days when the MDs we unchallenged by other upstart “physicians.”

Then again, the AMA leaders in keeping “physician” out of reach of other professions are probably not as comfortable with the additional 2008-2009 language: “MDs are also known as allopathic physicians.” The modifier “allopathic” is a hole in the dike through which may flow naturopathic physicians, chiropractic physicians, perhaps more acupuncture physicians, and the first through, osteopathic physicians.

Can Webster be a guide to who uses “physician”?

“Battle lines are being drawn,” Stephen Stills once wrote in his song “For What It’s Worth.” (10) The physician term is power. Professions so denominated stand at the top of the hill, waving about highfalutin reasons why their recognition as such is in the public good. The sub-text includes the know motivator that the title lands one on the road to the bank. The recent chiropractic battle with the Blues is a case in point. For what it’s worth, Stephen Stills’ next lines are that “nobody’s right if everybody’s wrong.”

Perhaps Webster can help us sort this out. I read 2 definitions while writing this column. Notably, neither states that “physician” denotes a practitioner who stands at the receiving end of medicine’s money shoot. That commercial application of the title has not reached definitional status.

The #1 definition for physician in the 50th anniversary edition of Webster’s New World Collegiate Dictionary (2001) is “a person licensed to practice medicine; a doctor of medicine.”

Common usage suggests that this refers only to MDs. Yet while some chiropractors are not sure they want to be associated with “medicine” and entry-level training for most acupuncturists is not presently as doctors, there is room in this definition to include all practitioners who are doctors and practice medicine. The New World Collegiate’s definition #2, however, shifts the puck toward the AMA hardliners: “Any medical doctor other than one specializing in surgery.”

I then turned to the Big Book, my inherited, coffee-table sized 2600 page Webster’s Third New International Dictionary inscribed With love to all, Happy Valentine’s Day, 1965, Dad. This weighty volume offers a potentially threatening definition #1: “A person skilled in the art of healing.”

Making the case for reimbursing the historic role of the physician

Does any practitioner of any stripe caught in the rapid-fire, reactive, insurance-based system who is merely dispensing therapies, whether legend drugs, herbs, remedies, needles, vitamins or manual manipulation, have the right to this title of physician as healer? Nobody’s right if everybody’s wrong, indeed. Definition #2 poses a similarly sobering, poorly reimbursed challenge: “One who restores.”

Trends noted here suggest that common and professional usage, despite the AMA’s rearguard actions, will increasingly accept that various healthcare professionals are physicians. This direction reflects the pluralism in the globe we inhabit and the populations practitioners serve. But maybe once U.S. medicine embodies the view that there is more than one road to becoming a “physician,” we should strip all of the professions of the pecuniary value of the term (before it is burned into Webster) and tell all physicians they can only earn their compensation back only if they show that their practices are “skilled in the art of healing” and in “restoring health.”

Better yet, these relative newcomers should join with their integrative MD colleagues and aggressively articulate the case for re-engaging, and creating payment for, these under-appreciated meanings of “physician.”